1. Recognizing and Preventing Overdose and Administering Naloxone www.OverdoseFreePA.pitt.edu Substance Use Disorder Treatment Professional Curricula Core Component 2 © 2014, Overdose Prevention Coalition

2. The OverdoseFreePA website is brought to you by the Overdose Prevention Coalition, a collaborative between: The Pennsylvania Department of Drug and Alcohol Programs (DDAP) The Single County Authorities (SCAs) of: Allegheny County Blair County Bucks County Butler County Dauphin County Delaware County Westmoreland County The Allegheny County Medical Examiner’s Office The Program Evaluation Research Unit, University of Pittsburgh School of Pharmacy The project is supported by a generous grant from the Pennsylvania Commission on Crime and Delinquency. Background Photo for Slide Set by Jason Pratt from Pittsburgh, PA (Trees and light) [CC-BY-2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

3. SAMHSA National Survey Past Month Nonmedical Use of Types of Psychotherapeutic Drugs among Persons Aged 12 or Older: 2002-2012 Substance Abuse and Mental Health Services Administration (SAMHSA), 2013

4. SAMHSA National Survey Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older: 2011-2012 SAMHSA, 2013

5. Past-Year Initiates for Specific Illicit Drugs Among Persons Age 12 or Older, 2008 Overview of Substance and Drug Use SAMHSA, 2009

6. Overdose An overdose means having too much of a drug or alcohol, or a mix of drugs and/or alcohol for your body to safely handle. Overdose can result in permanent brain damage, permanent organ damage or death. Overdose symptoms can look different depending what kinds of drugs were used. DDAP, 2014; Centers for Disease Control and Prevention (CDC), 2012

7. Overdose (cont’d) Drug overdose was the leading cause of injury death in the U.S. in 2010. Among people 25 to 64 years old, drug overdose caused more deaths than motor vehicle traffic crashes in 2010. CDC, 2012

8. Overdose Deaths in Pennsylvania Based on Pennsylvania Department of Health data, overdose deaths have been on the rise over the last two decades, with an increase in the rate of death from 2.7 to 15.4 per thousand Pennsylvanians. DRUG OVERDOSE DEATHS IN PENNSYLVANIA Year Number of Deaths PA Population Rate per 1,000 20111,90912,742,88615.4 20101,55012,702,37912.5 20081,52212,448,27912.6 20061,34412,440,62111.2 20041,27812,406,29210.6 200289512,335,0917.5 200089612,281,0547.4 199862812,001,4515.4 199663012,056,1125.4 199459612,052,4105.1 199244911,995,4053.8 199033311,881,6432.7 DDAP, 2014

9. Different drugs have different overdose symptoms. International Overdose Awareness Day (IOAD), 2014 It’s Good to Know …

10. Symptoms of Overdose Depending on the drug(s) involved, an overdose victim can exhibit different symptoms. It’s important to be able to recognize the symptoms of overdose. – Time is a factor. – Prescription pills are involved in about 60% of overdose deaths. IOAD, 2014; Jones, 2013

11. Signs of Alcohol Overdose: Confusion Difficulty remaining conscious Slow breathing or gaps in breathing Clammy skin Vomiting Seizures Slow heart rate Dulled responses Extremely low body temperature DDAP, 2014

12. Signs of Amphetamine/Other Stimulant (“Speed”) Overdose: Amphetamine-induced psychosis – (paranoia, hallucinations and/or delusions) Overheating Dehydration High blood pressure Seizures DDAP, 2014

13. Signs of Opioid (Heroin, Narcotic Pain Medication, Etc.) or Depressant (Xanax, Valium, Etc.) Overdose: Slow and shallow breathing Very sleepy and unable to talk Unconscious Blue lips or fingertips Snoring or gurgling sounds DDAP, 2014

14. Overdose Prevention Recognize the symptoms of an overdose. Call 911 immediately! Act quickly to administer rescue breathing. Administer Naloxone (Narcan ® ) if it’s available. DDAP, 2014 By Lviatour (Own work) [CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

15. Prescription Monitoring Programs: Reduce Diversion, not demonstrated to reduce overdose. Concern about increase in heroin use. Methadone and Suboxone treatment: Very effective Abstinence-based drug treatment: Risk of overdose increases when relapse occurs. Strategies for Reducing Overdose Deaths Bell, 2012

16. – Community Based Education: Risk Factors, Identification of Symptoms, Effective Response, including Rescue Breathing, Calling 911 and Naloxone Administration – Naloxone Prescription Programs – Physician Prescribing when prescribing opioids for pain Strategies for Reducing Overdose Deaths (cont’d) Bell, 2012

17. About Naloxone Naloxone reverses opioid-related sedation and respiratory depression = pure opioid antagonist – Not psychoactive, no abuse potential – May cause withdrawal symptoms May be administered IM, IV, SC, IN Acts within 2 to 8 minutes Lasts 30 to 90 minutes, overdose may return May be repeated Narcan® = naloxone naloxone ≠ Suboxone ≠ naltrexone Walley, 2013

18. Prefilled naloxone ampule Intranasal Administration Pro 1 st line for some local EMS RCTs: slower onset of action but milder withdrawal Acceptable to non-users No needle stick risk No disposal concerns Con Not FDA approved No large RCT Assembly required, subject to breakage High cost: – $40-50+ per kit Mucosal Atomization Device (MAD) Luer-lock syringe Walley, 2013 http://www.healthycommunitiesme.org/rx- prevention.html

19. Intranasal Administration (cont’d) Walley, 2013

20. When is Naloxone Prescribed? 1. Patient release after emergency medical care involving opioid OD/intoxication 2. Suspected history of illicit or nonmedical opioid use 3. High-dose opioid prescription (> 50 mg of morphine equivalence/day) 4. Any methadone prescription to opioid naïve patient Any opioid prescription and … a.smoking/COPD/emphysema/asthma or other respiratory illness b.renal dysfunction, hepatic disease c.known or suspected concurrent alcohol use d.concurrent benzodiazepine prescription e.concurrent SSRI or TCA anti-depressant prescription Powers, 2012

21. When is Naloxone Prescribed? (cont’d) 5.Prisoner released from custody 6.Release from opioid detoxification or mandatory abstinence program 7.Voluntary request from patient 8.Patients in methadone or buprenorphine detox/maintenance (for addiction or pain) 9.Patient may have difficulty accessing emergency medical services (distance, remoteness) 10.Other reasons? Powers, 2012

22. The Prescription Opioid Epidemic Deaths due to prescription opioid use have more than tripled in the past ten years across the U.S. Prescription opioids have been linked to a significant increase in overdose deaths in Pennsylvania. CDC, 2014; Sapatkin, 2014

23. Overdose is Preventable The best strategy for preventing overdose is to address SUD or pain management issues appropriately before they lead to overdose. NIDA, 2014 By Charlesjsharp (Own work) [CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons